On another, train-wreck freak-show fascination note, the results of Anna Nicole Smith's autopsy were released today. Kind of amazing, though not particularly surprising.

Summary:An abscess in her buttock related to injections of a unnamed drug.Multiple drugs which have sedating effects:

Chloral Hydrate (in toxic concentrations)

Ativan

Valium

Klonopin

Oxazepam

Benadryl

Methadone

Soma

Robaxin

Note: the list varies between the autopsy report and that in today's Seattle Times. Maybe someone can explain the discrepancy for me. Either way, it's a buttload of drugs. (Sorry for a truly awful though unintended pun.) The conclusion seems entirely reasonable -- accidental overdose. All of these drugs individually can cause respiratory depression and in combination, especially in a patient acutely ill with a bacterial infection, I can see respiratory arrest as a logical consequence.

One wonders how on earth she got these drugs. It's an impressive quantity. I gather she had a few personal physicians who would prescribe for her under a pseudonym. They may now be in trouble, if in fact they knew it was not her real name, and if they knew the amount of medicine she was taking. On the other hand, the sad truth is that patients lie and conceal information from their doctors, especially when drugs are involved. So the docs may have been duped to some degree. And she had been in the Caribbean, where drugs may be much easier to come by, especially if you have money. And of course, internet pharmacies abound. Given the variety of meds, I suspect multiple sources. Even the most unscrupulous pill-pushing docs would tend to consolidate the list a bit -- i.e. ativan or valium, but not both, since they are functionally identical.

Which brings me to reflect on benzodiazepine abuse. I thought, in medical school, that it was a disease of the repressed housewives of the 1960's and was no longer common. Sadly, it is not so -- in the ER, I see use, mis-use, and abuse of benzo's more than any other category of drug save narcotics. I hate it, because it puts me in a bind. The typical presentation is thus:

Patient presents for a somatiform complaint which is clearly affectively mediated. (in the old days this was called hypochondriasis, but I gather that term is politically incorrect these days.)During the work-up, they ask for something to help them calm down. Shortly before discharge the truth comes out -- they are out of their meds and need a refill. The variety and ingenuity of excuses are legion. Either the pills were stolen or the dog ate the prescription or they opened the cupboard and all the pills just fell into the toilet on accident or, rarely, "I just ate 'em all." And the original prescribing doctor is out of town or is unavailable for appointments or is a jerk and won't do refills or lost his license etc etc etc. So it is my problem and I have to figure out what to do about it.

Problem is that benzo withdrawal is dangerous and can cause potentially lethal seizures (unlike narcotic withdrawal which is miserable but generally harmless). So I have to either give in and refill the Rx, or send them out with a small risk of something very bad happening. There's not much middle ground, though you can punt with a really small prescription for a day or two. If they have been a few days without their meds, they are already detoxed and I can justify refusing to prescribe. But when they are actively withdrawing, or still on the meds, it's a tough situation with no good option.

And the worst thing is that benzos generally cause up-regulation of their receptors in the brain, so over time the patient requires escalating doses of the drug just to stave off crippling anxiety. And coming off the drug is really hard, emotionally. I've seen a lot of people just like the unfortunate Ms Smith in my ER - some just anxious, some withdrawing, some overdosed, and some dead. It's because of people like her, and the mode of her death, that I generally decline to prescribe these meds unless absolutely mandatory.

I finally got up the time to update my blogroll. It's amazing what a little enforced bedrest will do for one's ability to catch up on petty postponed organizational tasks. And it was either do this or try to clean out my email mailbox, and I just can't face that.

So you will now see more relevant and better sorted links over there to the right. I haven't spent a lot of time yet getting to know some of the new ones but I look forward to doing so.

Also, I wanted to bid a very fond farewell to Barbados Butterfly. She is an Australian surgeon with a biting wit and beautifully intimate writing whose hospital administration took offense at her blogging and thus her blog is no longer available. I hear she is doing well and I am glad for that. I do hope she can come back to blogging at a more opportune time because she has a beautiful voice.

I had a minor surgical procedure today (I'm just fine, thank you). As usual, when I am incognito, I can't help tweaking the medical professionals just a bit. And since this was the outpatient surgical center, nobody knew I was a doctor. So I had a pleasant time chatting with the nurses and receptionists, they brought me back and got me prepped and hooked up. We chatted a bit about the amazing pharmacopoeia found in Anna Nicole Smith's corpse. And then the anesthesiologist came in to do his pre-op bit, and going through his routine rapid-fire questions.

"We're going to be giving you an antibiotic in your IV. It's called Ancef. You're not allergic to anything, are you?" "No." (He starts the IV running. After a moment, I remember) "Though once I had anaphylaxis to Kefzol.""Did you take any medications this morning?" "No. Well, only my coumadin.""Why are you on coumadin?" "I don't know. They never told me."

Rolling down the hall to the OR my stomach growled audibly. I groaned a little and rubbed my stomach. "Man, I shouldn't have had so much Gatorade this morning"

As they positioned me on the table and I started feeling a little light-headed from the Fentanyl I told him, "I was told once I might have myasthenia gravis. I hope that's not a problem for you."

As I drifted off to sleep I told him I was going to be really pissed if I woke up with a colostomy. (I was not going in for an abdominal procedure.)

Fortunately, he had me figured out pretty quick. Which was good because I didn't actually want to get my case canceled. I really should be more careful, though, because payback can be a bitch. When I woke up I half-expected to see a faux colostomy bag taped to my belly.

To paraphrase Patrick O'Brien, nobody has ever taken so much pleasure from so very very little wit as I do.

I just came off the strangest shift. I worked a nine-hour overnight and saw about 22 or 23 patients. That is a nice pace -- busy but manageable. I never really caught up, but never fell too far behind. The weird thing? I saw two chief complaints:

Febrile child

Abdominal pain

Seriously, that's it. No falls, no headaches, no drunks (on an overnight!), no chest pains, no psych. Just febrile children and abdominal pains (in about a 2-1 ratio). It would have been cool if there had been a febrile child with a tummyache to get the cross-over, but it wasn't to be. Confusingly, the belly pains all got lined up in rooms 6, 7, 8, and 9. I almost told the wrong female that she was unexpectedly pregnant (oooops) but I caught myself just in time.

Pleasingly, most all the abdominal pains wound up with relatively definite diagnoses, and all of the kids were fine -- none "needed" an x-ray, IV, bloods, etc. For 90% I just gave my standard virus/fever speech and sent happy and reassured parents on their way. There were a couple of red eardrums I gave amoxicillin to.

The shift ends at 7, and I walked out the door at 7:05. Weird but satisfying.

25 March 2007

On another note, it is becoming more and more clear that Abu G lied when he said that he wasn't personally involved in the decision to fire eight US Attorneys. And they wonder why Leahy wants them under oath when they testify. It's because Bush and his gang have lied again and again and cannot possibly be trusted to tell the truth unless they face perjury charges if they do not. (and even then I wouldn't take them at their word.)

24 March 2007

Rush, on learning that Elizabeth Edwards has been diagnosed with Stage IV metastatic breast cancer:

What is their religion? I don't doubt they're religious people, but, we talked about this. Political people are different than you and I. And, you know, most people when told a family member's been diagnosed with the kind of cancer Elizabeth Edwards has, they turn to God. The Edwards turned to the campaign.Their religion is politics and the quest for the White House. And that's -- it's not just with them, I mean, it's part and parcel of political people -- undergo all this stuff, the media anal all over their private life being made public even by the candidates themselves -- it's all part of the drill.[...] If you're Barack Obama or Hillary Clinton, how do you now attack John Edwards? Not a problem for Hillary, the Clinton [inaudible] will find a way. But Barack, it's going to be a challenge. [...] What the Edwards campaign is going to do here is see what the reaction is within the ranks of Democrat [sic] voters -- as far as this announcement is concerned -- and then go on from there. If there is not a big jump, if this doesn't cause a breakout, if this doesn't cause a big uptick, then, at some point, Senator Edwards will probably have to suspend the campaign.

23 March 2007

Astute viewers will note the dilated large intestine on the scout, the free air in the retroperitoneum on the coronal reconstruction of the CT, and the liver metastases on the CT. Less apparent but visible is the obstructing lesion on the left of the bladder, most likely a sigmoid adenocarcinoma. Also visible on both images is the free air in the mediastinum.

All of which was unsuspected when the patient presented for abdominal pain and vomiting. That was an uncomfortable conversation, I can tell you. Very sad. The patient was admitted for comfort care.

Wow. One off-the-cuff post about the US Attorney scandal really brought out the right-wing trolls. Which is in itself fine, since I realize that a lot of readers of this blog are right of center. No offense to the sensible conservatives out there, but to the trolls:

Stop being stupid.

In particular, I am referring to the "Clinton fired all the US Attorneys, so there's no scandal when Bush fired some of his" argument which I have heard from multiple commenters and in personal emails. (Strangely, the emails have been far more vulgar and abusive than the comments; most all are anonymous.)

I'll explain this slowly and using small words for you:

US Attorneys are all political appointees, and at the beginning of a new administration they are all replaced with new appointees, just like the Cabinet and other political appointees. So yes, Clinton replaced all 93 US Attorneys at the beginning of his administration, just as GW Bush and Reagan did at the beginning of theirs.

This is different.

Allegedly (and once again, I am not claiming special insight or certainty) the AG's office in concert with political operatives in the White House selectively fired US Attorneys who they deemed not loyal to the Bush administration.

This is an abuse of power; the President clearly has the right to fire his employees at will, but the targeting of prosecutors who investigated republicans or failed to investigate democrats is clearly an attempt to use the power of the Department of Justice for political, partisan purposes, or at least to influence and undermine the independence of the US Attorneys. One need only look at the Watergate scandal for the corollary -- Nixon had articles of impeachment drawn up in no small part for the Saturday Night Massacre, in which he summarily dismissed the special prosecutor who was investigating the Watergate scandal.

There are differences between the two situations. For one, there is (as yet) no indication that the President was involved in the 2006 prosecutor purge. And of course, the US Attorneys targeted were not investigating the White House. So there is a huge disparity in the degree of gravity between the two cases. It seems that culpability in this case rests with the office of the AG and possibly the White House Counsel/Rove.

All Americans -- right or left -- should be disturbed by this abuse of power. The Department of Justice should never be used as a political tool. There is evidence of exactly that occuring. For example, a study published in 2006 showed that in the four years between 2000-2004, DoJ investigations of local elected officials targeted Democrats eight times more often than republicans! That this is derived out of partisan purposes is inarguable. Nobody with a shred of intellectual honesty can argue that local Democrats are an order of magnitude more corrupt that republicans. (Indeed, at the national level, the opposite would seem to be the case.)

So, to the conservative trolls out there, if you wish to support this abuse of the power of the Department of Justice, pause a moment and imagine what it will be like should President Clinton or Obama decide that turnabout is fair play and fill the offices of the US Attorneys with partisan hacks under orders to investigate only republicans and give the free pass to Democrats.

21 March 2007

All physicians hate JCAHO. Truly, it is an awful organization and they do awful things to the practice of medicine*. It seems like every year there is some new fad, some new measure that they are pushing down the throats of the people trying to practice medicine in a challenging environment.

I am sure there is some good that comes of JCAHO regulations. Their intentions may be good. But when you are the practicing doc (or nurse, God help them, the burden of the regs falls much harder on the nurses), trying to deal with a sick population, half of whom are uninsured, in an overcrowded ED with too few nurses and no inpatient beds and no specialists will to take call, the miniscule, petty, trivial, small-minded rules promulgated by this unelected bunch of bureaucrats can make you crazy.

For example, a couple of years ago, it was decreed that nothing could be stored under the sink in the ED. I have no idea why -- under the sink is a perfectly good storage place for non-medical supplies. They had to turn the ER upside down finding new legal storage places for the displaced stuff. And last year it was abbreviations. I agree that some abbreviations probably are confusing and should be clarified -- that's good common sense. But they came out with a list of dozens of abbreviations which are banned, many of which are perfectly clear (such as the use of L for Left and R for right). There is no appeal for their decisions, they are passed down from on high as infallible law, and woe betide the nursing manager if the department is singled out as deficient on a JCAHO survey.

The new rule, designed, it seems, to increase patient treatment times and decrease patient satisfaction and quality of care, is this: All non-emergent medications must be reviewed by a pharmacist and mixed (if necessary) by a pharmacist.Which sounds reasonable on the face of it until it collides with the hard reality: We don't have a pharmacist in the ED. There aren't enough pharmacists to go around as it is, and now, instead of keeping the drugs in the ER and mixing them at the point of service (which isn't that hard), we need to send up to the inpatient pharmacy, wait for the PharmD to get around to it in their workflow, and send it back down. And we are not even talking about the dangerous stuff, but routine meds like certain antibiotics. Another interruption to our workflow, another delay in patient care, just one more in the death of a thousand cuts that is making health care that much more of an unpleasant profession.

And the scary thing is that this is an improvement from the original draft regulation, which said that all meds had to be reviewed in advance by a pharmacist.

The tech, as per protocol, dropped the ECG on my desk within three minutes of its being completed, along with the chart. He was visibly excited. I glanced at the ECG and the triage note. In the standard terse nursing verbiage, it read "CC: Ground Level Fall. Too weak to get out of bed. No injury reported. No other complaints." There was an included prior ECG, which was normal. Today's looked like this:"Should I call the cath lab?" the tech asked. We pride ourselves in having the best door-to-dilation time in the region, and it's a key focus of our department protocols that patients with an "Acute MI" or heart attack need to be expedited to the cath lab. The tech had seen the computer interpretation of "ACUTE MI" and was rarin' to go.

I have learned not to trust the computer. The only thing it can reliably interpret is "Normal" and even then it is sometimes wrong.

So, as several of the commenters correctly guessed, I ordered a stat chemistry panel, and the serum potassium was resulted at 8.5 (normal = 3.5-4.5), which should not be surprising because, once I took the drastic step of meeting and interviewing the patient, he has kidney failure and is dialysis dependent. He was too weak to get out of bed for dialysis and so had missed his appointment, which was part of the reason his potassium was elevated. The other part? I'll get to that.

So, hyperkalemia (medicalese for "high potassium") is one of those things that is a true emergency, that can be immediately lethal if not treated, and one of the few things that really gets an ER doctor moving. Potassium is involved in maintaining the electrical gradient which allows muscle and nerve cells to function -- excessive potassium in the bloodstream poisons the ability of these cells to operate normally. This accounts for the patient's generalized weakness. The Bad Thing that can happen is that the heart muscle can be affected -- in this case, the heart muscle was no longer contracting briskly in unison over the usual 100 milliseconds or so, but rather contracting sluggishly over a period of 200 msec; you can see how wide and ugly the spikes (QRS complex) are on the above ECG. It was still pumping OK, but the risk is that this makes the heart very vulnerable to arrhythmia, that any minor disruption, like a premature beat, could induce irrecoverable ventricular fibrillation.

Fortunately for adrenaline junkies like me, there is an antidote: a cocktail of Calcium, Sodium Bicarbonate, and insulin, which can very quickly mitigate the effects of hyperkalemia. the bicarb and insulin activate ion pumps which move the potassium inside of cells, which temporarily "hides" the excess potassium from the heart. Calcium buffers the heart cell membranes and stabilizes them from the ill effects of the potassium. It's extremely gratifying. It doesn't fix the problem, but generally buys you enough time to get the patient to dialysis, which will remove the potassium from the bloodstream. Calcium works fastest and should always be given first in these situations. Here's how it worked for us:And the after-treatment ECG:Notice the nice narrow QRS complexes. Much better looking. And off he went for emergency dialysis.

And as for the "why" -- well, he had a dedicated and caring wife. She was very concerned about the general decline in his health since he had been on dialysis, and that in particular he was losing weight and malnourished because he no longer had the appetite he once did. So over the weekend, she went and got him some really nutritious vegetable juice -- V8.Chock full o' potassium. 470 mg per serving. Sheesh.

13 March 2007

I was listening to NPR this afternoon and heard something which literally sent a chill down my spine. Senator Pat Leahy, chairman of the Judiciary Committee, was being interviewed about the Great Prosecutor Purge. He was asked about his reaction when he heard in the media that Attorney General Gonzales had provided false information to Congress about the firings of the 8 US Attorneys:

"I just blew my stack. It was outrageous, because we had given the administration, the Department of Justice, every chance to come forward and tell us everything that happened. They assured us that they had told us everything that happened, and yet they left out some very, very key points. I saw the attorney general this morning in a meeting at the Supreme Court, and I told him that I was very, very unhappy with this — actually quite angry about it. [...] He said that he would be happy to come up and brief us some more. I said, "No, I've had enough of these briefings where ostensibly we're told everything; it turns out we weren't. The next time you come up will be before the full committee; it will be an open session; and you will be under oath."" (Emphasis original)

But what gave me the chill was not my simple partisan glee at anticipating Alberto "The Constitution does not contain an express grant of Habeas corpus" Gonzales' resignation (though I do relish the thought) but the simple thought that finally, after six years of complete neglect, Congress is finally exercising oversight again. No, we can't effect immediate policy changes or pull the troops out of Iraq on a moment's notice. But the grown-ups are back in charge on the Hill, and finally, someone with subpoena power, someone responsible, someone with an interest in being a check on this administration's abuse of power, is back at the reins and willing to actually fulfill the constitutional role of oversight again.

It's a terrible thing, having patients in the hallways. I hate it, the nurses hate it, the hospital administration hates it. And guess what? Patients hate it too. It's kind of like being in limbo, where you may or may not have a nurse assigned to you, and you may or may not see your doctor (or any staff member, depending on which corner you are shuffled off into), and people walk by you constantly without talking to you or making eye contact. It seems like the most common types of patients I see on the hallway gurneys are:

Drunks slowly metabolizing their way to freedom (often in 4-point restraints)

Demented geriatric patients awaiting ambulance transfer back to the warehouse nursing home

Little old ladies being admitted, waiting for a bed

Patients with police needing an "OK to book" exam

Three-year-old children with ear infections (who will never be seen if they have to wait for a regular bed)

Histrionic Anxiety/Chest Pain patients who came in via 911 but the charge nurse thinks is faking it.

Regular folks with moderate orthopedic injuries

I hate it when I have a "regular person" in the hallway. I need to do a lot of things which involve walking up and down the halls and every time I walk past them it's, well, awkward. I don't necessarily have an update or something new to say to them, and I can't exactly inquire how they're doing because I am going somewhere else and don't have the time to really listen to an answer. Yet I feel rude just ignoring them.

A lot of the other folks I am quite content to ignore, especially the drunks.

And of course I feel terrible for the parents of the children who get stuck in the hallway. (invariably close to the most foul-mouthed, abusive smelly drunk we have) Sure, they didn't need to be there, they could have gone to their doc in the morning, but their kid is sick and they got anxious, and their punishment is that they have to explain why that smelly man told the nurse to "go f*ck yourself, b*tch!" Not exactly what I would want for my kid.

Well, once we get the Death Star on line we won't have to deal with that anymore, I hope. For a year or two, until we outgrow the new place.

12 March 2007

Our facility is quite old. We see over 100,000 patients per year in an ED environment which includes:

1 trauma resuscitation bay

4 medical resuscitation beds

32 "regular" telemetry beds

6 fast track beds cannibalized to be regular tele beds

4 observation beds also so cannibalized

3 "real" fast track beds

For a total of 50 beds. There are also anywhere from 8-10 euphemistically named "Hallway beds" (basically spots to park a gurney which are now "official beds" with monitors and a dedicated chart slot since their occupancy rate is essentially 100%) and when the feces has truly hit the fan we will occasionally park a half dozen chairs in the hallways for the "quick & easy" patients who would otherwise never get a "real" bed.

And the physical plant is essentially the only rate-limiting factor in our ability to move patients through. The docs are well-staffed (overstaffed, some might say), and the nursing staffing could be better but is adequate, and the hospital is great when it comes to admissions (we never board patients in the ED more than 2-3 hours). There just isn't enough physical space to put any more patients (I have suggested bunk beds, but administration doesn't like the idea). And I get the feeling that the business would be there for us if we could build the capacity.

So we are building a new shop. I just got back from a planning meeting. It is going to be absolutely gargantuan, costing in the range of half a billion dollars, with an ED only slightly small than one in the Death Star. The footprint of the ED will be over a football field on each side, over 100,000 square feet, sporting 90 beds.

Ninety!

That's planned out as 4 "pods" of 20 beds each, and one ten-bed Fast Track. For comparison purposes, the median ED in the US is probably about 20 beds. It boggles the mind and scares the crap out of me.

You see, I have to run this joint. Not alone, of course, and thank god for that. But how on earth am I going to staff that place? I have a couple of years to get ready, fortunately, but consider the imponderables:

How many patients will there be? Will our volume jump 10% the first year? 15%? 20%?

How many docs will have to be on shift during peak hours?

How many during off hours?

What time of day will I flex up and down?

How many shifts will I need to schedule?

How many doctors will I need to employ to fill those shifts?

Should we get specialized peds ER docs? etc etc etc.

Oh dear lord. There are so many unknowables, and I need to recruit a year or two in advance to get staffed up for the expected surge in volumes. What if I hire too many? What if I hire too few? And that leaves aside the whole operational issues -- patient distribution and tracking, communication, etc. I joked that we'll need roller blades or segways just to get around. And if someone gets put in room 71 and the tech puts him in "Room 17" in the computer, we will never find him.

So, exciting, but I get palpitations and chest tightness just thinking about the challenge. Hey, and I'm a little sweaty and my left hand is sort of tingling . . . .

11 March 2007

10 March 2007

Damn. I just missed this somehow. The Washington Post is running a beer competition, aptly named the "Brewhaha," wherein they compare 32 national and local beers and select a national champion. I see that my personal favorite beer, Anchor Steam, has thus far made it through to the round of sixteen. Somehow Budweiser is still in the running, though, which makes me wonder about the quality of their taste-testers.

I am also pleased to see my local favorite, Red Hook, still in the running. I have tried, I think, 22 of the 32 entrants. (Pabst Blue Ribbon is still being brewed? Who knew?)

I can't resist lists. I don't know why. PZ Myers at Pharyngula threw out a list of "The Most Significant SF & Fantasy Books of the Last 50 Years, 1953-2002" -- I'm unclear of the exact origin of the list. I can't quite match PZ's geekitude, but I was pleased to see that I've read more than half of the books on the list.

The Lord of the Rings, J.R.R. Tolkien

The Foundation Trilogy, Isaac Asimov

Dune, Frank Herbert

Stranger in a Strange Land, Robert A. Heinlein

A Wizard of Earthsea, Ursula K. Le Guin

Neuromancer, William Gibson

Childhood's End, Arthur C. Clarke

Do Androids Dream of Electric Sheep?, Philip K. Dick

The Mists of Avalon, Marion Zimmer Bradley

Fahrenheit 451, Ray Bradbury

The Book of the New Sun, Gene Wolfe

A Canticle for Leibowitz, Walter M. Miller, Jr.

The Caves of Steel, Isaac Asimov

Children of the Atom, Wilmar Shiras

Cities in Flight, James Blish

The Colour of Magic, Terry Pratchett

Dangerous Visions, edited by Harlan Ellison

Deathbird Stories, Harlan Ellison

The Demolished Man, Alfred Bester

Dhalgren, Samuel R. Delany

Dragonflight, Anne McCaffrey

Ender's Game, Orson Scott Card

The First Chronicles of Thomas Covenant the Unbeliever, Stephen R. Donaldson

The Forever War, Joe Haldeman

Gateway, Frederik Pohl

Harry Potter and the Philosopher's Stone, J.K. Rowling

The Hitchhiker's Guide to the Galaxy, Douglas Adams

I Am Legend, Richard Matheson

Interview with the Vampire, Anne Rice

The Left Hand of Darkness, Ursula K. Le Guin

Little, Big, John Crowley

Lord of Light, Roger Zelazny

The Man in the High Castle, Philip K. Dick

Mission of Gravity, Hal Clement

More Than Human, Theodore Sturgeon

The Rediscovery of Man, Cordwainer Smith

On the Beach, Nevil Shute

Rendezvous with Rama, Arthur C. Clarke

Ringworld, Larry Niven

Rogue Moon, Algis Budrys

The Silmarillion, J.R.R. Tolkien

Slaughterhouse-5, Kurt Vonnegut

Snow Crash, Neal Stephenson

Stand on Zanzibar, John Brunner

The Stars My Destination, Alfred Bester

Starship Troopers, Robert A. Heinlein

Stormbringer, Michael Moorcock

The Sword of Shannara, Terry Brooks

Timescape, Gregory Benford

To Your Scattered Bodies Go, Philip Jose Farmer

And now I see I have something of a "to do" list -- obtain and read the ones not in bold. That should keep me busy for a while.

08 March 2007

As previously reported, my friend Matt will be shaving his head on St Patrick's day as a fund-raiser for children's cancer research.

Matt is doing this for the benefit of his cousin and my friend, Nathan, age six, who has been fighting a deadly type of cancer, neuroblastoma, for almost four years.The sad news is that Nathan has relapsed and is facing a tough fight. The good news is that he is feeling well and going to school and really enjoying life right now. Nathan has undergone a number of experimental treatments for his cancer, some of which may have helped slow the progression of his disease. Programs like St Baldrick's provide vital financial support to these experimental trials. So get yourself on over to Matt's page and cough up a couple of bucks to support kids' cancer research. Even small amounts like $10 or $20 are greatly appreciated. Also, you can see Matt's photo on his page. He's a funny-looking guy. Help make him even funnier-looking by paying to get him bald.

Also, pay a visit to Nathan's page and send him and his family some love.

06 March 2007

Scalpel has made it clear that he would prefer the federal government stay more or less out of the uninsured crisis, as he feels that, given adequate resources, local authorities can handle it better. (please correct if I misstate your thoughts, Scalpel.) Michael Negron over at TPMCafe has an interesting rundown on the various proposals which have been floated to address the situation. Here's one which ought to please the other irascible Texan:

Another approach, outlined by Henry Aaron and Stuart Butler, is the creation of a structured national program of state experimentation with approaches towards expanding insurance coverage. This program could be enacted through federal-state “covenants” that condition federal funds upon the adoption of congressionally-specific policy constraints and approaches aimed at a set of defined goals. The “policy toolbox” of presumptively approved insurance solutions would enable advocates of different approaches, typically divided by partisanship or ideology, to buy into the program in hopes of building a broader consensus in favor of their views. The toolbox may also have the virtue of expanding coverage while simultaneously shifting the political playing field to the states, as advocates lobby state governments to adopt one approach or another. This approach may require preemption of state benefit mandates by federal regulation to permit. Like the individual mandate, this approach could expand health insurance coverage across the country while leaving costs rooted in administrative overhead and quality and efficiency of care unattended.

Personally, I am not a fan of the 'local experimentation' model. The reason is highlighted by the disagreement between Scalpel and myself: his community apparently has great resources set up for for indigent/uninsured, while those in my community are inadequate for the need. If local communities are allowed to tinker with the options, it's guaranteed that some communities will screw it up and those people will suffer, and I feel that health care is important enough that it shouldn't vary by the accident of where you happen to live. It is true that a locally varying solution would be better than a universal solution that sucks, and I am really afraid of some half-assed please-nobody compromise will come out of this whole debate. I also admit that I have not yet read the full text of the Aaron-Butler proposal and I am feeling a bit too hypoxic and dehydrated after Karate to give it careful thought just now.

05 March 2007

It's never a good thing when the radiologist calls you when you are on shift. Radiologists are, to the best of my understanding, subterranean cave dwellers who prefer to communicate with the living via fax machine. When they do call you, it's never to discuss how great the weather is or to offer you free ice cream. No, when they call you it's because in the seclusion of their underground bunkers they have found something Very Bad[tm] on one of your patients.

In this case it was this:I am not a radiologist, but even I can read this. It is a CT scan of the abdomen, formatted in the coronal plane, which can be said to slice the body into "front" and "back" portions. The thing in the upper left hand of the image is the liver, which is infiltrated with several very large tumors. (Below, crudely outlined in red)(see a more-or-less normal liver on coronal CT here)This finding was not a particular surprise to the patient or her family. She had been seen in another ER in the past and had been told she probably had cancer, and had even been referred to an oncologist. She said she was turned away from the oncologist's office because she had no health insurance. I strongly suspect that she was turned away in error by a poorly-informed clerk or receptionist. In my experience, oncologists are the specialty least likely to discriminate based on finances. But there you have it. So, being poor, and, it must be said, not terribly intelligent or assertive, she had simply accepted that it was her fate to have cancer (she didn't even know what type). She kept working her low-wage menial job until the pain prevented her from working any more, and after she had been bed-ridden several days, the family brought her in against her will.

She now has a lethal disease. It is impossible to know whether the original oncologist could have offered her curative treatment. It is impossible to know whether she could have been detected earlier by standard screening techniques. Very likely she simply has a bad disease which was going to kill her regardless of her socioeconomic status. What we do know is this:

She has no health insurance.

As a result, she had no access to primary care and no chance at early detection.

The lack of health insurance presented a barrier to access to care even after diagnosis.

By ROBIN TONER and JANET ELDERPublished: March 2, 2007A majority of Americans say the federal government should guarantee health insurance to every American, especially children, and are willing to pay higher taxes to do it, according to the latest New York Times/CBS News poll.

(Emphasis mine) More than half of all respondents thought health care was the most important domestic issue facing the country. Half of respondents aid they would be willing to pay up to $500 more annually in taxes to achieve this goal. The consensus was that "the Federal Government should guarantee health insurance for all Americans" by a 64%-27% margin. However, there was not a clear preference for a single-payer government plan as opposed to mandated employer-based coverage. By a four-to-one margin, respondents rated universal health coverage as more important than extending Bush's tax cuts.

I am most impressed that this is perceived as a serious enough crisis that people are willing to pay more in personal taxes to reach a solution. I can't remember any other issue in my lifetime which evoked a willingness to pay more in taxes, even in anonymous polling (which is quite different from when the new taxes are actually passed through Congress).

I like to see this. Momentum is building for serious reform. Now all we need is to recapture the White House . . . that should be easy enough, right?

(Obligatory snark - in the same poll, Bush's numbers creep back into Nixon territory with an overall approval rating of 29% and an approval of 23% on Iraq)

An axiom in the ER is that bad things happen to good people. This was a police officer responding to an accident in the icy conditions:There was an associated proximal fibular fracture as well. And to add insult to injury, he also had a deep flank contusion from falling hard and landing right on his gun.

01 March 2007

And steel-reinforced side doors.And, especially, BMW's Head Protection System:Which is essentially an inflatable tube that pops out of the ceiling in the event of a side impact.Without which my head would certainly have struck the B-Pillar, as I was hit on the side, from behind, at an angle of about 45 degrees.

The details are mundane and unimportant -- a freak snowstorm and a steep hill combined to put my vehicle in the path of oncoming traffic. The engineering of the car's safety systems managed to take what could have been a Very Bad Thing and make it simply Very Annoying. I'm fine: a bit sore but otherwise completely unhurt.

Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

Disclaimer

This blog is for general discussion, education, entertainment and amusement. Nothing written here constitutes medical advice nor are any hypothetical cases discussed intended to be construed as medical advice. Please do not contact me with specific medical questions or concerns. All clinical cases on this blog are presented for educational or general interest purposes and every attempt has been made to ensure that patient confidentiality and HIPAA are respected. All cases are fictionalized, either in part or in whole, depending on how much I needed to embellish to make it a good story to protect patient privacy.

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